1. CGBI. Redeploy Key Evidence-Based, Highly Effective Preventive Interventions to a New Generation of Consumers and their Providers P ROTECT, P ROMOTE AND S UPPORT I NSPIRE, E DUCATE AND E MPOWER Early and Exclusive Breastfeeding to reduce infant mortality in the US Miriam H. Labbok, MD, MPH, IBCLC, FACPM, FABM, FILCA Professor and Director, Carolina Global Breastfeeding Institute (CGBI) Department of Maternal and Child Health University of North Carolina labbok@unc.edu

2. CGBI BREASTFEEDING IS A VERY CONFUSING ISSUE IN THE US…

3. CGBI Presentation Outline Optimal Infant Feeding Risks of Not Breastfeeding Trends and Challenges Can we afford it? Conclusions

4. CGBI What is “Optimal Infant Feeding”? Immediate pp skin-to-skin and breastfeeding within about one hour Six months exclusive breastfeeding*^ Continued breastfeeding with appropriate complementary foods and feeding for at least one year* or up to 2 years and beyond^ Related maternal nutrition and care*^ (Antenatal counseling and preparation) (Avoidance of unnecessary invasive birthing practices) (Cord clamping delay) (New complementary feeding guidance) (Birth Interval of 3-5 years) *AAP ^WHO AMERICAN ACADEMY OF PEDIATRICS, Breastfeeding and the Use of Human Milk, Section on Breastfeeding http://pediatrics.aappublications.org/content/115/2/496.fullhttp://pediatrics.aappublications.org/content/115/2/496.full

5. CGBI Breastfeeding and Survival Immediate postpartum: Breastfeeding within one hour could reduce neonatal mortality by 22% worldwide(0.86 million deaths averted) Edmond K, Peds. 2006;117(3):380-6 Neonatal: Possibly 55-87% of global neonatal mortality could be prevented with breastfeeding Darmstadt G et al, Lancet 2005; 365: 977–88 Post neonatal: Non-breastfed infant 25% more likely to die in US in postneonatal period Chen A and W Rogan. Peds. 2004, 113(5):435-439

6. CGBI AHRQ Systematic Review and Meta-Analysis* Any formula use/lack of breastfeeding is associated with an increase in the risk of: – non-specific gastroenteritis – asthma (no family hx) OR:1.25; 1.72 – obesity – type 1 diabetes OR: 1.67 (1.12–2.44) and type 2 OR: 2.44 (1.08, 5.56) – childhood leukemia – sudden infant death syndrome (SIDS) ** – necrotizing enterocolitis –severe lower respiratory tract infections OR: 1.5; 3.6 –otitis media pooled OR for any formula in 1st 3 mo: 2.00 (1.40, 2.78) –atopic dermatitis OR 2.27; 5.88 –hypertension –high cholesterol *Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Litt M, Trikalinos T, Lau J. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment Number 153. 2007 April; AHRQ Publication No. 07- E007. **Vennemans et al: EBF associated with a 50% reduction in SIDS

7. CGBI Academy of Breastfeeding Medicine For Mothers, lack of breastfeeding (or early cessation) associated with an increased risk of: type 2 diabetes, breast cancer, ovarian cancer, and maternal postpartum depression. Breastfeeding also found to: Lower BP ?Enhance immune system activity? Increase efficiency in nutrient metabolism Modify calcium metabolism Delay fertility return

8. CGBI –School performance/ “intelligence” –Upward mobility –Satiety –Birth Spacing –Epigenetics –Pyloric Stenosis If you need more reasons…

9. CGBI We’ve Come a Long Way: “You may feel some resistance to the idea of such intimacy with an infant who, at first, seems like a stranger. To some mothers it seems better to keep the baby at arm's length, so to speak, by feeding plans which are not so close.” Infant Care. US Children's Bureau, HEW. 1963 Breastfeeding reached a nadir in the late 1960s/early 1970s, especially in the White population Today, about 75% initiate breastfeeding However, only about 35% EBF3, <20% EBF 6

10. CGBI Data from CDC NIS breastfeeding data website

11. CGBI CIYCFC Labbok, 2008 Trends in rate of breastfeeding initiation for US population, and for WIC and Non-WIC populations Ross Mothers Survey and CDC National Immunization Survey

12. CGBI Challenges “Consumer” - Lack of: Time and place Paid maternity leave Unbiased information and education Skilled support Understanding of the differences between optimal breastfeeding, human milk feeding and formula feeding Social support Inspiration, education, empowerment Policy - Lack of support for: Breastfeeding - support is primarily for milk expression and storage Health worker education Full reimbursement for Lactation Consultants Paid maternity leave Protection against false and misleading advertising Programs that protect and promote Can we afford it? Provider - Lack of: Training Reimbursement Hospital structures, protocols and policies (often dictated by administration and insurance) Funding to study/ change/implement Definitions Support for themselves to have breastfed: leads to cognitive dissonance Ability to support

13. CGBI Cost-Benefit Calculation Benefits=$10.3 billion from reductions in MMR and IMR Costs, including paid maternity leave, hospital changes and clinical support=$6.84 billion  B -  C, or may be presented as a ratio, C:B $3.5 B Savings C:B - For every dollar spent, $1.66 in savings This calculation does not include mortality: DALYs Study in progress, Labbok et al

14. CGBI FOR CONSIDERATION/ EXPLORATION: All causes IM 201123,9076.05 1Congenital malformations, deformations and chromosomal abnormalities 4,9841.26 2Disorders related to short gestation and low birth weight, not elsewhere classified – 10% 4,1161.04-.06 3Sudden infant death syndrome – 50%1,711.43 -.13 4Newborn affected by maternal complications of pregnancy 1,578.40 5Accidents (unintentional injuries)1,089.28 6Newborn affected by complications of placenta, cord and membranes 992.25 7Bacterial sepsis of newborn – 25%526.13-.02 8Respiratory distress of newborn – 10%514.13 -.01 9Diseases of the circulatory system496.12 10Neonatal hemorrhage444.11...All other causes(Residual) – 5%7,4571.89-.06 Ref: National Vital Statistics Reports, Vol. 61, No. 6, page 54 5.75

15. CGBI Medicaid and Breastfeeding: Major Impact: Estimated 40-50% of births covered by Medicaid act Breastfeeding/lactation not mentioned in Medicaid statute or Federal Medicaid regulations A 2009 study 1 found that only: – 25 States covered breastfeeding education services, – 15 States covered individual lactation consultations, and – 31 States covered equipment rentals, such as pumps. A 2012 CMS issue brief 2 : – Defines “pregnancy-related services” to include ‘lactation services’ for up to 2 months. – Encourages states to cover lactation services as separately reimbursed “pregnancy-related services”. – Coverage of lactation services without cost-sharing will qualify for a 1 percentage point increase in federal medical assistance percentage (FMAP) in 2013, because primary care interventions to promote and support breastfeeding received USPSTF grade B. 1 GWU/Kaiser Family Foundation. State Medicaid Coverage of Perinatal Services: Summary of State Survey Findings, 2009. 2 CSM Issue Brief: Medicaid Coverage of Lactation Services. http://www.medicaid.gov/Medicaid-CHIP-Program- Information/By-Topics/Quality-of-Care/Downloads/Lactation_Services_IssueBrief_01102012.pdfhttp://www.medicaid.gov/Medicaid-CHIP-Program- Information/By-Topics/Quality-of-Care/Downloads/Lactation_Services_IssueBrief_01102012.pdf

16. CGBI Action Needed: Medicaid and Breastfeeding States may, and should be encouraged to: – Reimburse lactation services through one of eight Medicaid coverage categories (e.g., hospital services, EPSDT, physician, nurse-midwife, nurse practitioner). – Use available billing codes available for: Lactation Consultation (face-to-face visit), (‘licensed practitioners’) Postpartum Care and Examination of “Lactating” Mother, Manual Breast Pump purchase, Hospital Grade Electric Breast Pump rental and Individual Electric Breast Pump purchase. – Conduct projects with managed care plans to reduce variation in practice.

17. CGBI Conclusions Propose that we cannot afford not to support women to breastfeed optimally. Translating these projected savings into policy and program change at the national level requires: – Action by Medicaid – Further modification of WIC – Specific attention to this issue in the ACA and further Health Care Reform to support breastfeeding, not only human milk feeding – Collaboration beyond HHS – Preemptive planning to address resistance by commercial formula interests. Conclusions: It would be very cost beneficial for the US to fully support breastfeeding.

18. CGBI Thank you